Dual Component Educational Program to Improve Medical-Surgical Nurses’ Knowledge and Self-Efficacy of Severe Sepsis and Septic Shock

University of Kentucky University of Kentucky

UKnowledge

UKnowledge

DNP Projects College of Nursing

2015

Dual Component Educational Program to Improve

Dual Component Educational Program to Improve

Medical-Surgical Nurses’ Knowledge and Self-Efficacy of Severe Sepsis

Surgical Nurses’ Knowledge and Self-Efficacy of Severe Sepsis

and Septic Shock

and Septic Shock

University of Kentucky, [email protected]

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The document mentioned above has been reviewed and accepted by the student’s advisor, on behalf of the advisory committee, and by the Assistant Dean for MSN and DNP Studies, on behalf of the program; we verify that this is the final, approved version of the student's DNP Project including all changes required by the advisory committee. The undersigned agree to abide by the statements above.

Duska S. Bethel, Student Dr. Melanie Hardin-Pierce, Advisor

Final DNP Capstone Report

Dual Component Educational Program to Improve Medical-Surgical Nurses’ Knowledge and Self-Efficacy of Severe Sepsis and Septic Shock

Duska Bethel, BSN, RN

University of Kentucky College of Nursing

Fall 2015

Melanie Hardin-Pierce, DNP, RN, APRN, ACNP-BC—Committee Chair Karen Butler, DNP, MSN, RN—Committee Member

Dedication

This capstone project is dedicated to my husband and my children. Wesley, thank you for always knowing my worth even when I did not. Miles and Elliot, I hope my actions in life are strong enough that you can one day say that I led by example.

♫♪ “Always remember there was nothing worth sharing like the love that let us share our name.” ♫♪

Who I am today is a direct reflection of the love my late grandfather, Charles Henry, gave me. The meaningful conversations and experiences we shared throughout my childhood provided me with resilience, a desire to do good, and the understanding that one should “step out” of their person to fully embrace others and achieve a better understanding of the world.

Acknowledgements

I would like to acknowledge and thank Dr. Melanie Hardin-Pierce, my advisor and committee chair, for all your involvement in my educational and professional growth— you are my guru. Special attention to Dr. Karen Butler, my committee member, for making me feel significant on the first day we met as well as your enthusiasm when I asked you to assist me with my project. I want to specifically recognize and thank Dr. Kevin Williams, my clinical mentor. Your presence throughout my professional career will have a lasting impact—your candor has always and will always be appreciated. Thank you Dr. Lynn Jenson for lending me your ear and providing your expertise as I developed my simulation. I wouldn’t have been able to do it without you. To Whitney Kurtz-Oglive, thank you for your comments and suggestions as my first manuscript was developed—what an amazing gift you possess. Thanks to Amanda Wiggins for helping with the organization of the statistical section of this capstone. To those women I look up to the most in nursing: Teresa Lynn—I’ll never be able to articulate how meaningful your guidance was for me as I developed my own nursing knowledge and skills; Corey Keith—you’ve supported me professionally as I grew as a nurse and had faith in my abilities; Christy Littrell, you helped me become strong and confident in my actions. I want to thank Mike King, Phillip Knight, Shawnell Toler, Stacey Glick, Jeri Winstead and Erica Fields for helping me carry out this project. Much thanks to all the employees at Baptist Health Madisonville who supported me as I wore every emotion on my sleeves. Darah, thanks for supporting me emotionally and providing me both friendship and coffee. Final thanks to Maryann Lancaster for all the experiences we’ve shared. You know just how real the DNP struggle is, and you should know that The Inn was just not the same without you.

Table of Contents

Acknowledgements ………...iii

List of Tables………..vi

List of Figures ………...vii

Introduction/DNP Practice Inquiry Project ……….1

Manuscript 1: Integrative Literature Review: High Fidelity Simulation Impact on Acute Care Registered Nurses in the Medical-Surgical Setting …..………. 5

Manuscript 2: Analysis of Clinical Guideline: Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 …..…… 24

Manuscript 3: Dual Component Educational Program to Improve Medical-Surgical Nurses’ Knowledge and Self-Efficacy of Severe Sepsis and Septic Shock …………... 43

Practice Inquiry Conclusion ……...………...………... 74

Appendix A………... 77 Appendix B ……….…. 79 Appendix C ……….. 84 Appendix D………... 87 Appendix E ……….. 88 Appendix F ………... 92 Appendix G………... 93 iv

Appendix H………....94

Appendix I .………...………....95

Appendix J .………...………....97

Appendix K ………...………. 103

Appendix L ……….... 104

DNP Practice Inquiry Project References ………...………105

List of Tables

Manuscript 1:

Table 1: Results of high-fidelity simulation education in the acute care setting……….…12 Table 2: Evidence Grading Schema...………..22 Table 3: Level of Evidence Synthesis……...……….23 Manuscript 2:

Table 1: Evaluator score results using the AGREE II Instrument for the Surviving Sepsis Campaign Guidelines……….… 30 Table 2: Standardized domain scores using the AGREE II Instrument for the Surviving Sepsis Campaign Guidelines……….……… 40 Manuscript 3:

Table 1: Demographic characteristics of sample ………..…….… 58 Table 2: Pre and post education knowledge and self-efficacy scores …...……… 59

List of Figures

Manuscript 3:

Figure 1: Procedure for implementing the dual component educational

intervention ……….. 51

Introduction to Final DNP Practice Inquiry Project Duska S. Bethel, BSN, RN

University of Kentucky

Sepsis is manifested by a spectrum of clinical signs and symptoms that are produced by an immune response to an infection. The continuum of sepsis ranges from simple sepsis to septic shock and without timely and appropriate intervention leads to death. Although patients with sepsis can deteriorate rapidly, they usually exhibit early warning signs with fever being the primary initial change (Gauer, 2013). Important for patients whose health status is guarded is the need for close monitoring through multiple observations, identification of deterioration, and timely, appropriate interventions (Luettel, Beaumon & Healy, 2007).

Poor knowledge, skill, and self-efficacy levels have been correlated with nurse failure to identify and respond to patient deterioration (Luettel, Beaumon & Healy, 2007). Staff development is the process by which registered nurses are formally educated to update and maintain clinical competency. Choosing which educational modality that is utilized in the acute care setting is dependent on the organization’s resources and time available to educate nurses. There is little research that focuses on identifying which educational modality is superior in terms of cost benefit and utility, effectiveness, and preference.

Registered nurses need more than didactic education in order to maximize their clinical competence so that they can independently and sufficiently function (Cook et al., 2001). Evidence supports designing educational programs that offer interactive experience so that knowledge, skills, and self-efficacy levels can be improved (Brannon et al, 2008; Cant & Cooper, 2010, Cook et al. 2011; Rosen et al., 2012). Simulation-based education has been shown to be a particularly effective means of promoting clinical competency and critical thinking skills (McGaghie et al., 2010; Rosen et al., 2012). Although simulation

itself can vary in complexity and level of fidelity, educational experiences that include feedback, debriefing, or guided reflection have demonstrated an ability to facilitate the link between theory and practice, increase knowledge synthesis, and promotes insight (Decker, 2008). Increased exposure time to simulation has been identified as a dominating factor that offer advantages in learner outcomes (Cant & Cooper, 2010; McGaghie et al., 2010).

The overall purpose of this practice inquiry project is to implement a dual component educational program at Baptist Health Madisonville, a hospital part of the Baptist Healthcare System in Madisonville, Kentucky, and evaluate the changes in nurse knowledge and self-efficacy levels after they receive didactic and interactive education. The first manuscript is an integrative literature review of studies published between 2005 and 2014 that have implemented educational interventions utilizing simulation in the acute care setting specifically on medical-surgical units. The findings from this review revealed a surprising knowledge gap in the use of high fidelity simulation outside the academic setting and whether this level of fidelity is cost effective or superior to lower levels of fidelity. The study recommends healthcare organizations utilize low to medium fidelity simulation in an effort to increase the engaging experiences of staff nurses. The second manuscript serves to analyze the Surviving Sepsis Campaign (SSC) Guidelines for management of severe sepsis and septic shock using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument. Using the Agree II Instrument facilitates a quality guideline assessment in terms of scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. The final manuscript is a write up of the results of implementing a pilot educational program that includes both didactic and simulation experiences in an attempt to improve

the knowledge and self-efficacy levels of medical-surgical registered nurses so that they may better recognize patient deterioration, specifically from sepsis, and respond appropriately and expediently.

Manuscript 1

Integrative Literature Review: High Fidelity Simulation Impact on Acute Care Registered Nurses in the Medical-Surgical Setting

Duska S. Bethel University of Kentucky

Fall 2015

Abstract

The purpose of this review is to understand the impact of programs that use high fidelity simulation as their interactive method on a nurse’s knowledge, skill, and self-efficacy levels in the acute care setting and to specifically research if high-fidelity simulation is the superior educational modality. Typically, it is the medical-surgical nurses who are with a patient during acute changes in condition, and who manage a patient in a guarded, but not critical, health status. It is important for the nurses to provide appropriate care, meaning adequate assessment and timely interventions since sepsis usually exhibits early warning signs. Staff development is necessary for nurses to build knowledge, skills and self-efficacy so that are able to independently and effectively function. In the current hospital setting many educational modalities are used for staff development of registered nurses and include didactic methods with interactive methods, including simulation. High fidelity simulation has shown to be effective at training bedside nurses when the intent is to improve knowledge, skills, and/or perceived self-efficacy. It has the potential to meet learning needs for new nurses in orientation as well as experienced staff nurses during clinical development. A literature search was conducted in CINAHL and PUBMED for original research studies with available full text published between 2005 and 2014. Nine articles met inclusion criteria and the results imply there is not enough evidence to support a practice change at this time with regard to supporting the utilization of high fidelity simulation as the best way to influence the nurse’s knowledge, skills and attitudes in the acute care setting.

Keywords: knowledge, skills, self-efficacy, simulation, high fidelity,

medical-surgical nurse, education

Introduction Background Information

Jeffries (2005) defines simulation as “activities that mimic the reality of a clinical environment and are designed to demonstrate procedures, decision-making, and critical thinking through techniques such as role playing and the use of devices such as interactive videos or mannequins.” Simulation varies in the level of fidelity ranging from low to high. Low fidelity simulations are case studies or basic mannequins. High fidelity simulation utilizes standardize patients or computer-based mannequins. The goal of simulation is to improve the existing knowledge of the learner so that the learner gains the confidence needed to apply the information gained in the clinical setting (Jeffries, 2005). High fidelity simulations are primarily used in academia, and most of the research regarding high fidelity simulation experiences has focused on the impact of simulation in the college/university setting and its effect on nursing students (Sharp et al., 2014).

There is validity in using simulation because it encourages full engagement of the learner and that educational programs that focus on learner engagement, decision making and realistic patient responses might be more useful when learning complex content as well as identifying the needs of the learner (Brannan et al., 2008; Rosen et al., 2012). Simulated experiences offer the opportunity for gains in knowledge, critical thinking ability, satisfaction, and confidence.

Focus of the Problem

Research suggests that educational interventions that are designed to actively engage the learner positively influence knowledge, skill, and/or self-efficacy levels (Brannan et al., 2008; Cant & Cooper, 2010, Cook et al., 2011). Didactic methods cannot

maximize new or inexperienced nurses’ clinical competence so that they can independently and sufficiently function during their transition from the student nurse to the licensed registered nurse (Cook et al., 2001). There is ample evidence that educational programs which offer interactive experiences are consistently associated with large effects for outcomes of knowledge, skills, and self-efficacy levels (Brannon et al, 2008; Cant & Cooper, 2010, Cook et al. 2011; Rosen et al., 2012).

Simulation-based education has been shown to be a particularly effective means of promoting clinical competency and critical thinking skills (McGaghie et al., 2010; Rosen et al., 2012). Although simulation itself can vary in complexity and level of fidelity, educational experiences that include feedback, debriefing, or guided reflection have demonstrated an ability to facilitate the link between theory and practice, increase knowledge synthesis, and promotes insight (Decker, 2008). Those educational interventions that increase exposure time to simulations have been identified as a dominating factor that offer advantages that result in improved learner outcomes (Cant & Cooper, 2010; McGaghie et al., 2010).

Hospitals and organizations, especially those not considered “teaching” facilities, are probably unlikely to use simulation as a means to educate staff or maintain their clinical competence. This could be due to the fact that there is, although growing, limited research that supports the correlation between high fidelity simulations with a proven increase in skills and knowledge. Whether engaging in these particular simulation experiences correlates with safer care and improved patient outcomes is uncertain (Hallenbeck, 2012; Lucas, 2014).

It was suggested that technology-enhanced simulations are associated with better outcomes in knowledge and confidence for the learner than didactic education alone (Cant & Cooper, 2010; Cook et al., 2011; Gordon & Buckley, 2009). Simulated learning needs to include a method that allows the learner to understand the link between theory and practice; it is this primary element of simulated experiences that some researchers are identifying as the unique feature that is the reason for the positive impact reported and why these researchers are calling for broader use of simulation-based education (Brannan et al., 2008; Decker et al., 2008; McGaghie et al., 2010). This concept was also presented when Disher and colleagues (2014) and Gordon and Buckley (2009) reported that debriefing after simulation allows the learner to review performance and clinical pearls, which are defined as “small bits of free standing, clinically relevant information based on experience or observation” (Lorin et al., 2008).

High fidelity simulations may offer advantages over lower fidelity simulations and that repetitive practices involving simulations have been associated with improved learner outcomes, suggesting a “dose-response” relationship in that “more practice yields better results” (Cant & Cooper, 2010). It is implied that high fidelity simulation is effective at training bedside nurses because knowledge scores improve after training, and it has the potential to meet learning needs for new nurses in orientation as well as experienced staff nurses during clinical development (Disher et al., 2014; Gordon & Buckley, 2009; Lucas, 2014).

Purpose of the Review

The rationale for this inquiry is to conduct an integrative review pertaining to the impact of interactive educational programs for registered nurses as they continue their

education in the professional setting. The goal of this review is to understand the impact of programs that use high fidelity simulation as their interactive method on a nurse’s knowledge, skill, and self-efficacy levels in the acute care setting. The area of interest is in acute care setting, and the primary nurse population of interest is medical, surgical, and/or telemetry nurses, either new or experienced. This integrative review should add a better understanding of the current use of high fidelity simulation in the acute care setting among registered nurses working in the medical, surgical, or telemetry setting. The PICOT question which guided this inquiry was “among registered nurses working in the acute care setting, does the use of high fidelity simulation improve clinical knowledge, skills, or confidence self-efficacy?”

Methods

Through the University of Kentucky’s Medical Center Library, an integrative literature search was performed using the U.S. National Library of Medicine National Institutes of Health (PubMed) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Various combinations of the keywords effect, impact,

outcome, nurse education, instruction, fidelity, simulation, knowledge, skills, attitude, confidence, and competence were used. The following MeSH terms were used: impact OR effect OR outcome AND nurse OR nursing NOT breast AND education OR educational

OR interactive OR fidelity OR simulation AND knowledge OR competence AND skills OR

behavior AND attitude OR confidence. This produced a search that was too broad and

therefore the search was simplified using the keywords high, fidelity, simulation, and

nursing with the MeSH term used as follows: high AND fidelity AND simulation AND

nursing. This produced a more manageable search that was also more specific to the

PICOT question.

General inclusion criteria were studies published between 2006 and 2014, in the English language, peer reviewed articles, studies conducted in western countries including Australia, Canada, UK, and the USA. Studies met the inclusion criteria if: the setting focused on medical-surgical environments in the acute care setting and educated registered nurses about deteriorating patients using high fidelity simulation experiences; if studies focused on registered nurses engaging in educational programs geared toward healthcare professionals and not nursing students. Studies were excluded if the setting was obstetrics, pediatrics, end-of-life care, home care, the operating room, or intensive care, if the educational programs were designed for nursing students and not registered nurses, and if the study measured impact on patients as the sole outcome.

Results

The search produced 274 articles. The title of each article was reviewed for potential relevance resulting in 27 articles selected. All abstracts were retrieved and their relevance to the aim of this review assessed. This resulted in 18 articles which were screened at the full text stage. A total of 9 articles met inclusion criteria and were used in the integrative review (see Table 1). The breakdown of the articles include a randomized control trial (n=1), non-randomized control trial (n=1), retrospective descriptive studies (n=3), expert opinion articles (n=2), and quasi-experimental pre-test/post-test studies (n=2).

Author & Year Design Sample Purpose Findings Implications Level

Ackermann, Kenny, & Walker, 2007

Descriptive study 21 new RNs Impact on nurse confidence; implementation of the use of HFS for new registered nurses

Increased confidence in dealing with emergencies; improved socialization to the setting.

HFS provides enhanced educational experiences for new RNs to develop critical thinking, decision making, and confidence.

VI

Beyea, Slattery, & von Reyn, 2010

Descriptive study; pretest and posttest

260 new RNs at an academic medical center

Measure global confidence, competence, and readiness for independent practice using the Readiness for Entry-Into-Practice (self-efficacy) instrument.

HPS and simulated scenarios rapidly increased new RN competencies, confidence, and self-assessed readiness to provide care to patients (p < .001). Decreased length of orientation, turnover rate.

Integrating simulation to nurse residency programs offer consistent, replicable orientation processes and supports the ability to evaluate competency development, provides standardized experiences and evaluations, and detects learning needs.

VI

Decker, Sportsman, Puetz, & Billings, 2008

Expert opinion N/A To educators on the evolution of simulation

Simulation can both teach and evaluate individuals or groups of individuals

Additional research is needed to provide the evidence to support integrating simulation in RN competency testing.

VII

Disher, Burgum, Desai, Fallon, Hart, Aduddell, 2014 Quasi experimental. Pre-post on knowledge, self-confidence 23 cardiac step-down unit nurses

The effects of a unit-based, HFS on a cardiac step-down unit RN’s ability to identify and manage deteriorating patients

Significantly higher knowledge, skill, and attitude levels

Unit based, high fidelity simulation an effective training approach for bed side nursing

III

Gordon & Buckley, 2009

Non-randomized control trial

50 medical-surgical RNs

The effect of simulation on medical-surgical nurses’ perceived ability and confidence in responding to patient clinical emergencies

Medical-surgical nurses’ confidence, perceived skills during patient clinical emergencies enhanced following simulations.

RN ability to transfer the increased confidence, perceived advanced skills following simulation to clinical environment needs investigation.

III

Lucas, 2014 Expert opinion N/A Identifies opportunities for employers to use high-fidelity simulation-based learning in continuing competency and staff development for practicing RNs.

Quality of care – HFS meets quality needs. System flow & access: competent, confident nurses avoid crisis. Return on investment = $864 per learner (3-days of HFS); avoidance of additional hospital days save $1,600 – $8,000.

Practicing nurses are expected to maintain competency in the face of increased workload and patient acuity. Little literature on the use of HFS to develop competence, confidence in practicing nurses.

VII

Scherer, Bruce, & Runkawatt, 2007 Quasi-experiment; pre/post-test; convenience sample randomly assigned. 23 RNs; experimental group (n=13) or control group (n=10)

Study to compare efficacy of HFS vs case study on knowledge and confidence in managing a cardiac event.

No significant difference in knowledge test scores; case study (control) group felt significantly more confident (p = .040).

Simulation and case study presentation had similar outcomes; both groups felt their experience was valuable.

III

Sheperd, Kelly, Skene, & White, 2007 Randomized controlled trial 74 RNs. 3 groups (SDL), SDL plus PowerPoint; SDL plus low fidelity simulation

Study to determine if knowledge of RNs who completed a simulation learning activity would be superior to those who completed traditional learning activities.

Simulation group had significantly higher (p < 0.001) knowledge test results than those with SDL and PowerPoint groups.

Simulation effective educational tool for teaching patient assessment, improving knowledge, skills to RNs. May decrease time required to become clinically proficient and improve nurse confidence.

II

Williams & Chong, 2010 Single descriptive study 9 RNs from a healthcare facility in Australia

Discussion of the implementation of a program to train RNs to recognize deteriorating patients and appropriately calling an early response team alert

Staff satisfied with the education. Improvement in patient outcomes in post-critical events. Increased nursing confidence and increased confidence of medical staff nurse.

Educational programs can increase nurse confidence and are therefore useful for staff development.

Level VI

Table 1. Results of High-Fidelity Simulation Education in the Acute Care Setting

Synthesis

Overall, most of the included articles were able to demonstrate improvement in nurses’ knowledge, skill, and self-efficacy levels through the utilization of high fidelity simulation (Beyea at al., 2010; Disher et al., 2014; Gordon & Buckley, 2009; Sheperd et al., 2007). Expert opinion also supports the use of simulation as a teaching and evaluation strategy although it is acknowledged that there is little literature on the use of simulation as an effective means to develop knowledge, skill, and self-efficacy levels in practicing nurses (Decker, 2008; Lucas, 2014). Both Decker and colleagues (2008) and Lucas and colleagues (2014) report that how advantageous high fidelity simulation is dependent on the topic, context, and method of simulation. This inconsistency in validity and reliability reflect a possible explanation as to why healthcare organizations have been hesitant to embrace this educational innovation as readily as academia has.

Williams and Chong (2010) described providing an educational program that serves to train registered nurses on how to appropriately recognize deteriorating patients and respond in a time appropriate manner with adequate nursing interventions. This study resulted in increased staff nurse self-efficacy, satisfaction with the educational program, and improved patient outcomes, all of which support the usefulness of topic-specific educational programs in staff development. Hospitals have recently been implementing educational programs for new nurse graduates as a means to decrease orientation time and improve new nurse competency and self-efficacy levels (Ackermann et al., 2007; Beyea et al., 2010; Sheperd et al., 2007; Williams & Chong, 2010).

Healthcare organizations must consider the impact on patient safety and quality of care provided when choosing their investments that affect system flow, access to services,

and return (Lucas, 2014). Based on the limited number articles found in this review, there seems to be a lack of evidence that supports high fidelity simulation as being the best tool to refine skills, confidence, and/or knowledge, either as nursing students or among nurses in the acute care setting.

Only two studies sought to compare high fidelity simulation to low or moderate-fidelity simulation or to didactic intervention alone. Sheperd and colleagues (2007) compared three interventions: self-directed learning (SDL), SDL with PowerPoint presentation, and low fidelity simulation to determine if the simulated learning activity was superior to the traditional educational interventions. The result of this study showed that the simulation group had a significant increase in knowledge compared to both the SDL group and the PowerPoint groups. The second study compared the efficacy of high fidelity simulation with case studies on nurse knowledge and self-efficacy levels in managing a cardiac event (Scherer et al., 2007); this study showed no significant difference in knowledge levels and in fact reported an increase in confidence level in the nurses who took part in the case study control group.

Appraisal of Evidence

The hierarchical evidence in this integrative review varies from level II to level VII (see Table 2 and Table 3). These articles clearly point out that interactive educational programs, specifically those which offer simulated experiences, are consistently associated with large effects for outcomes of knowledge, skills, and confidence levels. Limiting factors common to these studies included the studies being largely inconsistent. However, the variation among learners, instructional design, simulation mode, and outcome measurement resulted in heterogeneity, which implies that simulated education can be

provided to nurses as learners and can include a variety of topics. The Institute of Medicine (2001) identified simulation as a strategy to improve knowledge and skills of healthcare professionals which indicates that nurses at all levels may benefit from interactive educational experiences. A gap in this analysis is that it is not generalizable. Separate research would need to be carried out to make implications for student nurses and registered nurses outside of the medical-surgical setting. Major gaps to this analysis include lack of generalizability of the information to student nurses in the college setting.

Although some articles discuss the level of simulation or the length of time exposed to simulation, no study identifies what simulation mode is most effective at influencing the outcome on knowledge, skills, or confidence levels. There is a lack of evidence to support the claim that high fidelity simulation is the best tool to refine skills and knowledge. Future studies should focus on the possible correlation between the quality of education provided and impact on the learner’s knowledge and skill level (Hallenbeck, 2012).

Implications Knowledge Gaps

There is a surprising knowledge gap in whether high fidelity simulations are cost effective for healthcare organizations. Healthcare organizations must know if high fidelity simulation can be tailored to help the acute care nurse identify and communicate patient needs, meet quality needs, promote the competence and confidence needed so that nurses improve system flow and access by avoiding crisis, and avoid additional hospital days to improve patient flow (Lucas, 2014). Healthcare organizations would benefit from cost-utility analyses to compare the varying fidelity levels of simulation to determine if the extra

costs associated with high fidelity simulation justifies the differences, if any, of knowledge, skill, and/or self-efficacy scores of low or medium-fidelity simulation. From efficiency and quality improvement perspectives it is important to remember that just because an intervention increases nurses’ confidence in their ability to do something doesn’t mean that those nurses actually get any better at the task. Sometimes an educational intervention will increase confidence without increasing actual ability. Research is needed to understand the relationship between high fidelity simulation and whether an increase in knowledge, skills, and self-efficacy correlates with improved efficiency, better patient outcomes, and/or increased compliance to policies and protocols.

Evidence to Support Practice Change

There is not enough evidence to support a practice change at this time with regard to supporting the utilization of high fidelity simulation as the best way to influence the nurse’s knowledge, skills and attitudes in the acute care setting. Research has yet to identify where high fidelity simulation may be best suited. The current suggests it is dependent on topic, context, and method, and educators within healthcare organizations must be fully competent and prepared to implement simulated programs so that this educational strategy can be used at its highest capacity (Beyea et al., 2010; Decker et al., 2008). The variability in the results of two of the studies that sought to compare high fidelity simulation with lower levels of fidelity indicate that more evidence is needed to solidify a call to change educational modalities for staff development in the acute care setting (Scherer et al., 2007; Sheperd et al., 2007).

Overall, the quality of simulated experiences for healthcare professionals is low (McGaghie et al., 2010; Rosen et al., 2012). Not only is the number of studies small but

there is little literature on the use of high fidelity simulation to develop practicing nurses’ competence, confidence, or satisfaction (Lucas, 2014; Sharp et al., 2014).

Recommendations

In an effort to embrace the innovative technology that has been proven thus far to improve the knowledge, skills, and attitudes of nurses, at least in the educational setting, a possible solution that can be logically recommended for healthcare organizations is for them to utilize simulated programs that offer low to medium fidelity and to increase the time involved in simulated experiences on the nurse both in orientation and in the clinical competence-building environment. This will allow for pioneering technology to be used while large knowledge gaps exist to the point of not being able to justify such a huge financial investment or potential expenses (Decker et al., 2008; Lucas, 2014). Educational hospitals should focus their research on the impact on high fidelity simulators among nurses in the acute care setting. There is currently little research on deteriorating patient conditions based on cardiovascular, respiratory, or neurologic dysfunction, and this would be a promising area for future research in the acute care setting.

Conclusion

It is often the staff nurses who are present and manage a patient in a guarded status before care is escalated and provided in the intensive or critical care setting. It is because of this that future research and simulated educational experiences should focus on the medical-surgical nurse and the deteriorating patient, specifically how the staff nurse can be educated to differentiate early versus late signs of deterioration as well as establishing trends in changes (Disher et al., 2014). It is imperative for practicing nurses in the acute care setting to maintain clinical competency despite challenges such as increased task load

and a higher level of patient acuity. The reality is that simulation does indeed seem to be a unique method for teaching and evaluating a nurses technical abilities (Decker et al., 2008; Lucas, 2014).

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Beyea, S., Slattery, M., & von Reyn, L. (2010). Outcomes of a simulation-based nurse residency program. Clinical Simulation in Nursing, 6(5).

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simulation-based medical education research: 2003-2009. MEDU Medical

Education, 44(1), 50-63.

Melnyk, B., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing and

Healthcare: A guide to bed practice (2nd ed.). Philadelphia, Pennsylvania:

Wolters Kluwer Health/Lippincott Williams & Wilkins

Rosen, M., Hunt, E., Pronovost, P., Federowicz, M., & Weaver, S. (2012). In situ simulation in continuing education for the health care professions: a systematic review. Journal of Continuing Education in the Health Professions, 32(4), 243-254.

Scherer, Y., Bruce, S., & Runkawatt, V. (2007). A comparison of clinical simulation and case study presentation on nurse practitioner students' knowledge and confidence

in managing a cardiac event. International Journal of Nursing Education

Scholarship, 4(1), article 22.

Sharp, P., Newberry, L., Fleishauer, M., & Doucette, J. (2014). High-fidelity simulation and its nursing impact in the acute care setting. Nurs Manage, 45(7), 32-39. Shepherd, I., Kelly, C., Skene, F., & White, K. (2007). Enhancing graduate nurses' health

assessment knowledge and skills using low-fidelity adult human simulation.

Simulation in Healthcare: Journal of the Society for Simulation in Healthcare, 2(1), 16-24.

Evidence Grading Schema (Melnyk & Fineout-Overholt, 2011, p. 12) Level Description

Level I Evidence from a systematic review or meta-analyses of all relevant RCTs

Level II Evidence obtained from well-designed RCTs

Level III Evidence obtained from well-designed controlled trials without randomization

Level IV Evidence from well-designed case-control and cohort studies

Level V Evidence from systematic reviews of descriptive and qualitative studies

Level VI Evidence from a single descriptive or qualitative study

Level VII Evidence from the option of authorities and/or reports of expert committees

Table 2. Evidence grading schema (Melnyk & Fineout-Overholt, 2011).

LEGEND

1 = Ackermann, Kenny, & Walker, 2007; 2 = Beyea, Slattery, & von Reyn, 2010; 3 = Decker, Sportsman, Puetz, & Billings, 2008; 4= Disher, Burgum, Desai, Fallon, Hart, Aduddell, 2014; 5 = Gordon & Buckley, 2009; 6 = Lucas, 2014; 7 = Scherer, Bruce, & Runkawatt, 2007; 8 = Sheperd, Kelly, Skene, & White, 2007; 9 = Williams & Chong, 2010

Table 3. Level of Evidence Synthesis Table

Citation/Article 1 2 3 4 5 6 7 8 9

Level I: Systematic review, meta-analysis Level II: Randomized

controlled trial X

Level III: Controlled

trial, no randomization X X X Level IV: Case-control,

cohort study

Level V: Systematic review of qualitative or descriptive studies

Level VI: Qualitative/

descriptive study, implementation

projects

X X X

Level VII: Expert

opinion, consensus X X

Manuscript 2

Analysis of Clinical Guideline: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

Duska S. Bethel, BSN, RN University of Kentucky

Fall 2015

Abstract

Sepsis is manifested by a spectrum of clinical signs and symptoms that are produced by an immune response to an infection, which is characterized by systemic inflammation and coagulation. Sepsis is a continuum that ranges from systemic inflammatory response syndrome (SIRS) to septic shock. Sepsis can progress to multiple organ dysfunction syndrome and, without timely and appropriate intervention, to death. The incidence and prevalence of sepsis is rising and the mortality rate is high, equal to that of myocardial infarction. Sepsis is the most expensive condition treated in the acute care setting and also a mysterious one since the pathogen responsible for over half the cases of sepsis goes unidentified. The Surviving Sepsis Campaign Guidelines was first published in 2004 in an attempt to reduce the mortality rate associated with sepsis through a comprehensive literature review which subsequently led to recommendations for best practice in the management and treatment of severe sepsis and septic shock.

The purpose of this manuscript is to use the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument to analyze the Surviving Sepsis Campaign (SSC) Guidelines for management of severe sepsis and septic shock. The use of the AGREE II Instrument facilitates a quality guideline assessment in terms of the tool’s 6 domains which are scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence

Keywords: sepsis, severe sepsis, septic shock, bundles, surviving sepsis campaign

Analysis of Clinical Guideline: Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

Introduction Definitions

The American College of Chest Physicians developed the following four definitions relevant to sepsis over twenty years ago as a way to standardize the approach to these clinical conditions, and these terms are still being used today: systemic

inflammatory response syndrome, sepsis, severe sepsis, and septic shock (Bone et al.,

1992).

Systemic Inflammatory Response Syndrome

Systemic inflammatory response syndrome (SIRS) is an inflammatory response from a non-specific insult and must include at least two of the following signs and/or symptoms: core body temperature greater than 38 degrees Celsius or less than 36 degrees Celsius, heart rate greater than 90 beats per minutes, respiratory rate greater than 20 per minute or PaCO2 less than 32 mmHg, a white blood cell count greater than 12,000 mm3 or less than 4,000 mm3, acute mental status changes, or hyperglycemia defined as a glucose level higher than 140mg/dL in the absence of previous diagnosed diabetes mellitus (Bone et al., 1992; Dellinger et al., 2013).

Sepsis and severe sepsis

Sepsis includes the SIRS response with a presumed or confirmed infection. Severe sepsis is defined as sepsis that is associated with organ dysfunction manifested by hypoperfusion and organ dysfunction signs. Hypoperfusion is indicated by a systolic blood pressure reading of less than 90 mmHg, mean arterial pressure less than 65 mmHg, or a

drop in systolic blood pressure of at least 40 mmHg. Organ dysfunction signs include decreased perfusion: capillary refill greater than 3 seconds, skin mottling, cold extremities, and/or lactate greater than 2 mmol/L; respiratory: SpO2 less than 90 percent on room air, PaO2 less than 70 mmHg; hepatic: jaundice, total bilirubin greater than 2 mg/dL, increased liver function tests, and/or increased prothrombin time; renal: creatinine greater than 2.0 mg/dL, urine output less than 0.5 mL/kg/hour for at least two hours; central nervous system: altered consciousness, confusion, or psychosis; coagulopathy: international normalized ratio greater than 1.5 or aPTT greater than 60 seconds, thrombocytopenia where platelets are less than 100,000 mm3; or splanchnic circulation: absent bowel sounds (Dellinger et al., 2013).

Septic shock

Septic shock includes the signs of severe sepsis only hypotension persists despite adequate fluid resuscitation; the systolic blood pressure is less than 90 mmHg or mean arterial pressure is less than 65 mmHg and serum lactate level is higher than 4.0 mmol/L (Bone et al., 1992; Dellinger et al., 2013).

Incidence and Prevalence

One out of every 23 patients in the hospital is diagnosed with sepsis and 4,600 patients are diagnosed each day making it the sixth most common reason for hospitalization (Elixhauser, Friedman, & Stranges, 2011). The number of patients diagnosed with sepsis has more than doubled between 1993 and 2009 (Elixhauser, Friedman, & Stranges, 2011).

Mortality Rate

SIRS rapidly progress into sepsis, and without appropriate and adequate treatment, is life threatening. The morality rates of severe sepsis and septic shock are high:

approximately 35% of patients with severe sepsis and 50% of those diagnosed with septic shock will die (Bone et al., 2003). Sepsis is the primary cause of 20% of the annual in-hospital deaths which is the same as the annual mortality rate from acute myocardial infarction (Martin et al., 2003). Morality rates in the United States have increased 5.6% from 1993 to 2003 (Dombrovskiy et al., 2007). Mortality rate is time-dependent: early resuscitation, which means interventions within the first 6 hours of sepsis recognition, decreases mortality rate by 25% compared to late resuscitation (Jones et al., 2008).

Financial Impact

According to Torio and Andrews (2013), the cost to treat sepsis in 2011 was more than $20 billion. Sepsis is the most expensive reason for hospitalization: it costs $33,000 on average to treat sepsis (Eber et al., 2009). Between 1993 and 2009, scientists identified a 153% increase in hospital length of stay associated with sepsis (Elixhauser, Friedman, & Stranges, 2009). Patients with sepsis have hospital stays 11 days longer than patients without sepsis (Eber et al., 2009).

Infection Sources

More than half of sepsis cases have an unknown source of infection (Elixhauser, Friedman, & Stranges, 2011). Escherichia. Coli is the most common organism identified in patients with a primary diagnosis of sepsis, and Methicillin-resistant staphylococcus aureus or MRSA is the most common organism identified in patients with a secondary diagnosis of sepsis (Elixhauser, Friedman, & Stranges, 2011).

Surviving Sepsis Campaign

Dellinger and colleagues (2013) defined sepsis and septic shock and discussed its significance offering an introduction to support the need for change. In 2012 international

guidelines from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine were published which recommends the screening and management of sepsis, severe sepsis, and septic shock for adult inpatients through the implementation of a “sepsis bundle” that follows evidenced based practice known as the Surviving Sepsis Campaign (SSC) (Dellinger et al., 2013).

The AGREE II Instrument

The AGREE II instrument was published in 2010 as a replacement to the original AGREE Instrument and is now comprised of 6 quality domains covering 23-items. The tool itself has been endorsed by the Canadian Institute of Health and the Canadian Medical Association Journal as well as several other health care organizations. Utilization of the AGREE II instrument will facilitate a quality assessment of the SSC Guidelines. The 6 AGREE II Instrument domains and items include the following: the scope and purpose which ask about the guideline’s aim, health questions, and target population; stakeholder involvement which asks whether the appropriate stakeholders developed the guideline as well as if the guideline represents the intended users’ view; rigor of development helps the evaluator identify the process and methods to formulate and update the guideline; clarity of presentation is concerned with the guideline’s language, structure and format; applicability poses questions related to barriers and facilitators to implementation, uptake strategies, and resources accompanied with the guideline; and editorial independence allows for the evaluator to, as unbiasedly as possible, given an overall recommendation regarding the guideline’s use. The instrument also concludes with a rating of the guideline overall (Brouwers et al., 2010) (see Table 1).

Domain Item Evaluator 1 Evaluator 2 Evaluator 3 Evaluator 4 1 1 4 4 4 4 2 4 4 4 4 3 4 4 4 4 2 4 4 4 4 4 5 4 3 4 4 6 4 4 4 4 3 7 4 4 4 4 8 4 4 4 4 9 4 4 3 4 10 4 4 4 3 11 4 4 4 4 12 4 4 4 4 13 4 4 4 4 14 3 4 4 4 4 15 4 4 4 4 16 4 4 4 4 17 4 4 4 4 5 18 3 4 4 4 19 4 4 3 4 20 4 4 4 4 21 4 4 4 4 6 22 3 4 4 4 23 4 4 4 4

Table 1. Evaluator Score Results

Scope and Purpose

The framework provided from the AGREE II Instrument will be utilized to assess the quality of the SSC Guidelines. The purpose of this paper is to analyze the SSC Guidelines for management of severe sepsis and septic shock using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument (Brouwers et al., 2010).

The objectives of the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock: 2012” is to provide an update to the previous guidelines which were last published in 2008 (Dellinger et al, 2013). The health intents of the SSC Guideline are to screen, diagnose, and treat the target population of those patients with severe sepsis and septic shock (Dellinger et al., 2013). The expected benefit of applying the evidence-based recommendations is the improved outcomes, specifically decreased mortality rate for critically ill patients with severe sepsis or septic shock as well as the positive influence on bedside healthcare practitioner behavior so that the burden of sepsis is reduced worldwide (Dellinger et al., 2013, p. 583).

The health problem addressed by the guideline is the management of severe sepsis and septic shock. First, initial resuscitation and infection issues are introduced and includes the screening for sepsis, diagnosis of sepsis, antimicrobial therapy, source control, and infection prevention. Second, hemodynamic support and adjunctive therapy is discussed and include fluid therapy of severe sepsis as well as the use of vasopressors, inotropic therapy, and corticosteroids. Next, support therapy of severe sepsis is included in regards to blood product administration, the use of immunoglobulins and selenium, and the history of recommendations regarding the use of recombinant Activated Protein C. The SSC Guideline also addresses mechanical ventilation of sepsis-induced respiratory distress

syndrome, glucose control, renal replacement therapy, bicarbonate therapy, deep vein thrombosis (DVT) prophylaxis, stress ulcer prophylaxis, and nutrition. Setting goals of care are recommended and pediatric differences are also considered.

The SSC Guideline is meant to apply to clinicians who are responsible for identifying, managing and treating sepsis in the acute care setting. The SSC Guidelines are pertinent to many members of the healthcare team in the intensive care unit and non-intensive care unit settings.

Stakeholder Involvement

The SSC guidelines were originally published in 2004. The 2004 SSC guidelines incorporated evidence available through 2003. The 2008 SSC guidelines searched literature through the end of 2007, and the 2012 guidelines included the evidence available up until fall of 2012. Members of the consensus committee were selected by the two main sponsoring organizations, the Society of Critical Care Medicine and European Society of Intensive Care Medicine. These two governing bodies appointed the two co-chairs, Dr. R. Phillip Dellinger and Dr. Rui Moreno. There were a total of 68 international experts who represented 30 international organizations.

Members of the 2012 SSC Guidelines Committee are listed in the first appendices at the end of the article. The 30 international organizations who had representation on the consensus committee and endorse the SSC guidelines include the American Association of Critical-Care Nurses, American College of Chest Physicians, American College of Emergency Physicians, American Thoracic Society, Asia Pacific Association of Critical Care Medicine, Australian and New Zealand Intensive Care Society, Brazilian Society of Critical Care, Canadian Critical Care Society, Chinese Society of Critical Care Medicine,

Chinese Society of Critical Care Medicine−China Medical Association, Emirates Intensive Care Society, European Respiratory Society, European Society of Clinical Microbiology and Infectious Diseases, European Society of Intensive Care Medicine, European Society of Pediatric and Neonatal Intensive Care, Infectious Diseases Society of America, Indian Society of Critical Care Medicine, International Pan Arabian Critical Care Medicine Society, Japanese Association for Acute Medicine, Japanese Society of Intensive Care Medicine, Pediatric Acute Lung Injury and Sepsis Investigators, Society for Academic Emergency Medicine, Society of Critical Care Medicine, Society of Hospital Medicine, Surgical Infection Society, World Federation of Critical Care Nurses, World Federation of Pediatric Intensive and Critical Care Societies, World Federation of Societies of Intensive and Critical Care Medicine. The German Sepsis Society and the Latin American Sepsis Institute also participated in the development and endorsement of the guidelines.

The name of each member, expertise discipline, institution, geographical location and a description of the member’s role in the guideline’s development are included on the third page of the article. The members of the committee were appointed either by their sponsoring organization because of their sepsis expertise or by the co-chairs to address content needs during the development process. Group heads were first selected then group members were selected based on the specific area of expertise—each group was assigned the task of drafting the initial update of the 2008 guidelines. Four clinicians with Grading of Recommendations Assessment, Development and Evaluation (GRADE) process application expertise created the GRADE group also known as the Evidence-Based Medicine (EBM) group and were responsible for developing the SSC guideline. All the

groups met either in person, via teleconferences, or electronic-based discussions. The final draft of the 2012 guideline was constructed via a meeting of all group heads.

The development process of the guidelines was a formal review of the literature for each clearly defined question. The committee members worked in subgroups to carefully identify and input the search terms. It is made clear that external review was conducted to get views, experiences and evidence of, not only experts, but the target stakeholders and therefore, can assume that providers of acute care and those involved in the care of patients with sepsis will find these guidelines relevant: physicians, nurse practitioners, and nurses. The SSC Guidelines Committee hopes to influence the behavior of bedside healthcare practitioners who manage and treat severe sepsis and septic shock (Dellinger et al., 2013).

Rigor of Development

The EBM group led the first consensus meeting where the procedures for literature review and table development for analysis were dictated. Separate literature searches were performed for each question, either previously used in the 2004 guideline or newly generated for general-topic searches or recent trial results. The time period searched for new literature was January 2008 until the fall of 2012. Specific search terms used included sepsis, severe sepsis, septic shock, and sepsis syndrome, but also included each group’s general topic area as well as key words specific to each question posed.

The reviewers searched for pertinent meta-analyses, systematic reviews, and randomized controlled trials and were required to use at least one general database such as MEDLINE or EMBASE as well as the Cochrane Library. The use of additional databases were optional. The evidence was assessed using the GRADE system which assessed

quality that ranges from high (A) to very low (D) and the strength of each recommendation from strong (1) to weak (2).

Recommendations were divided into three groups: those targeting severe sepsis; those targeting care of the critically ill patient that is considered high priority in severe sepsis; and pediatric considerations. The GRADE system was used as a way to consider clinical importance in the quality of evidence obtained so that a direct comparison of desired effects versus undesired effects could be made. Desired effects included beneficial health outcomes, a lesser burden on staff and patients, and cost savings. Undesired effects include harm to health, more burden on staff and patients, and greater costs. The committee’s strong recommendation of an intervention implies that the benefits outweigh the risks.

The committee was discouraged from making strong recommendations unless the quality of evidence was strong. When the guideline states “we recommend” then it is implied that the quality of evidence was strong. The committee used weak recommendations when evidence was of low quality and the benefits should outweigh the risks. When the guideline states “we suggest” then it is implied that the committee has a lack of confidence in the intervention’s ability to result in benefits over harm. The revision process was funded through a Gordon and Betty Irene Moore Foundation grant. Deborah McBride was acknowledged for externally reviewing and editing the manuscript.

The SSC consensus committee summarize that the guidelines will be updated regularly to reflect new interventions published and as current interventions are modified. The future for the guidelines include its adjustments to ensure certainty of

recommendations and reflection of the dynamic and evolving process of optimally treating severe sepsis and septic shock.

Clarity of Presentation

The SSC Guidelines have recommendations that are specific and unambiguous for the initial resuscitation and infection issues of severe sepsis and septic shock, hemodynamic support and adjunctive therapy in severe sepsis and septic shock, supportive therapy of severe sepsis, and pediatric considerations in severe sepsis. Different options for management of severe sepsis and septic shock are presented due to the fact that these recommendations, although some strong, are not yet standards of care as verified by practice data. The flow of the guidelines are clear and work as an efficient reference to key stakeholders.

The recommendations are easily found and answer the questions that have been addressed by the guidelines. Under each section is the recommendations which are numbered. After the recommendations a rationale follows that includes the referenced article along with the quality and strength via the GRADE system structured. Key recommendations are provided in tables or figures. The tables included in the guidelines include the following: diagnostic criteria for sepsis; diagnostic criteria for severe sepsis; determination of the quality of evidence; factors determining strong versus weak recommendation; recommendations for initial resuscitation and infection issues; recommendations for hemodynamic support and adjunctive therapy; norepinephrine compared with dopamine in severe sepsis summary of evidence; recommendations for other supportive therapies of severe sepsis; and recommendations regarding special considerations in pediatrics. Two figures are present in the articles which are the SSC

bundles and the algorithm for time sensitive, goal-directed stepwise management of hemodynamic support in infants and children.

Application

The SSC guidelines are meant to provide a source of guidance to clinicians caring for patients with severe sepsis or septic shock in both the intensive care unit and non-intensive care unit settings. The application of these interventions in the management and treatment of severe sepsis and septic shock are meant to be best practice since these interventions do not yet represent standards of care.

The SSC, supported by the Society of Critical Care Medicine, has a website that gives advice and provides tools to put the SSC Guidelines into practice. The website has a complete implementation and improvement guide. There are also sections on the website that provide access to bundle resources, data collection tips, implementation tools, and improvement monitoring. A resource tab is present as well to provided upcoming events with sepsis experts, web-based education, literature that influences sepsis care, and techniques to implement the SSC Guidelines all in an attempt to reduce the mortality rate associated with sepsis (survivingsepsis.org). The website from the Society of Critical Care Medicine offer posters, brochures, phone applications, and algorithms as clinician resources.

It is acknowledged that limited resources in some institutions or countries might prevent clinicians from carrying out all the interventions. Data collection and analysis of compliance to the SSC bundles are necessary when implementing improvement efforts in the care of patients with severe sepsis and septic shock. The SSC has provided an electronic data collection tool as well as paper screening tools (survivingsepsis.org).

Editorial Independence

The entire guideline process was achieved without industry funding to the committee members, industry input was not accepted during the guidelines development, and industry representation was not present at any of the meetings. The committee members have not received honoraria for their role in the guidelines process. The development of a formal conflict of interest policy was developed at the beginning and enforced throughout the process. The entire conflict of interest process was outlined and described in Appendix B. Each committee member was required to disclose any conflict of interest at the beginning of the process and annually by answering nine specific questions. Members were either prohibited from participation or permitted to participate. If the member’s disclosure was not able to provide a conclusion then they were sent to a conflict review committee where a participation or prohibition decision was made. If permitted it was either because the member’s disclosure was deemed not a source of bias or the member was placed in a group to preclude bias or provide disclosure. Nine members had conflict of interests that were resolved by prohibiting them from heading a group and assigning them to groups where the least conflict of interest was possible.

Recommendation

The SSC consensus committee feels the guidelines outlined and discussed in the article will be useful in the emergency department, medical/telemetry units, or the intensive care unit (ICU) settings. The SSC specifically states that the “greatest improvement can be made through education and process change for those caring for severe sepsis patients in the non-ICU setting and across the spectrum of acute care” (Dellinger et al., 2013, p. 583). This statement can be supported by the abundance of resources that have concluded

that the speed and appropriateness of therapy administered within the initial hours after severe sepsis development are likely to influence outcome. If healthcare providers can identify patients with sepsis early and intervene in a timely and adequate manner then the patients’ chance of dying from the continuum of sepsis is reduced—this forms the theoretical basis for the development of the bundles associated with the SSC Guidelines.

The third, updated 2012 SSC Guidelines provide more certainty to their recommendations due to the additional evidence that has been published since the second Guidelines’ release in 2008. The bulk of SSC Guidelines provide recommendations for management and treatment of severe sepsis and septic shock. Both of these terms are used to describe a point on the sepsis continuum. Without proper and timely treatment, death from the inflammatory response to infection is highly likely. That being said, although the SSC Guidelines specifically recommends the screening for sepsis, the article itself is targets clinicians responsible for the treatment and management of severe sepsis and septic shock, and the bundles include diagnostic and initial resuscitation strategies. These bundles have major implications for the nurses who carry out the orders included in the sepsis bundles. Assuming knowledge level correlates to performance level then future efforts should be made to improve knowledge of severe sepsis and septic shock to all pertinent members of the healthcare team. This includes educational strategies in settings beyond the emergency department and the ICU. The SSC website has education which is geared toward quality improvement strategies and data collection techniques, but does not provide educational information that targets the medical/telemetry nurse.

The SSC Guidelines should be used as a consensus for best practice in the management and treatment of severe sepsis and septic shock. The majority of the

interventions carry the weight of strong recommendations and where lower quality evidence-based suggestions are present, the guidelines provide a concrete rationale and transparency to the potential debate among those interventions. Using the AGREE II instrument, the SSC Guidelines have been analyzed and determined to originate from a solid literature review by sepsis experts and will be helpful to healthcare providers (see Table 2).

Domain 1 Domain 2 Domain 3 Domain 4 Domain 5 Domain 6 Obtained score 48 47 125 48 62 31 Minimum possible score 12 12 32 12 16 8 Maximum possible score 48 48 128 48 64 32 Domain Score 1.000 0.972 0.969 1.0 0.958 0.958 Domain Percent 100% 97.2% 96.9% 100% 95.8% 95.8%

Standardized domain score =

(obtained score – min. possible score) ÷ (max. possible score – min. possible score) Table 2. Standardized domain scores